COMPLETE ALL FIELDS BELOW, INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED.

Last Name: ____________________________ First Name: ____________________________ M.I. _____

Date of Birth: _____/_____/_____ Have you been convicted of a Felony? Yes: _____ No: _____

Since your last renewal/recertification:

Have you moved? Yes: _____ No: ______ If yes, your new residence is:

Street __________________________________________ Apt# _______

City ________________________________ State ______ Zip ________ County _____________

Has your mailing address* changed? Yes: _____ No: _____ If yes, your mailing address is:

Street/PO Box __________________________________________ Apt# _______

City ________________________________ State ______ Zip ________ County _____________  

(*Your mailing address cannot be your employers address unless your are self-employed)

Daytime phone # :(____) __________________ Home Phone # :(____) ___________________

Cell Phone # :(____) ___________________ Email: _______________________________________

EMPLOYER/BUSINESS INFORMATION

Business Name: _____________________________________ NYSDEC registration# (if applicable) ________

Address: ___________________________________City _____________________ State _______ Zip_______

AFFIRMATION, 1.) I acknowledge that I WILL keep records, file annual reports, submit to inspections, apply pesticides and adhere to all New

York State laws in Article 33 of the Environmental Conservation Law (ECL), and all rules and regulations in 6NYCRR part 325;

2.) I authorize DEC and DMV to produce an ID card bearing my DMV photo. I understand DMV will send this card to the address I maintain with DEC; THAT DEC and DMV will use my DMV photo to manufacture all my subsequent ID Cards for as long as I maintain my applicator certification.

False statements made herein or on any attachments submitted by me, are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law.

Pesticide Applicator/Technician Renewal/Recertification

Application Form

CERTIFICATION ID#:

Bureau of Pesticides Management 625 Broadway - 9th Floor Albany NY 12233-7254 Phone: 518-402-8748 www.dec.ny.gov

Signature__________________________________________________________Date________________

Application Checklist

Fee

When your application has been determined to be complete an invoice with payment instructions will be mailed to you.

Certified Commercial Pesticide Applicator and Technician RecertificationFee: $450 every 3 years for the first category of certification and $150every 3 years for each additional category of certification. (1 category =$450, 2 categories = $600, 3 categories = $750, etc)

Commercial Pesticide Applicator and Technician certified in Category 3a only or Category 3b onlyFee due at Renewal Date: $150 for a one year certificationFee due at Recertification Date: $450 for a three year certificationTo determine your recertification date please go to http://www.dec.ny.gov/nyspad/

Aquatic Antifouling Paint Applicator Fee: $450 every 3 years.

Certified Private Applicator Fee: $25 every 5 years.

Second or subsequent private applicator working on same farm: $5 every5 years (please provide name and certification number of primaryapplicator)

Completed Application Form

Recertification Credits (if required)

You are required to submit ORIGINAL certificates for courses taken before 9/8/2014

Mail to:NYSDEC Bureau of Pesticides Management625 Broadway 9th FloorAlbany, NY 12233-7254